Cases reported "Tuberculosis, Meningeal"

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1/28. Focal limb dystonia in a patient with a cerebellar mass.

    BACKGROUND: Focal dystonia of acute onset is indicative of a structural lesion in the nervous system. Cerebellar lesions have rarely been associated with dystonia. CASE DESCRIPTION: A 42-year-old woman was admitted to the neurology ward because of fever, confusion, and gait unsteadiness. She was diagnosed as having tuberculous meningitis, and, after a few days of antituberculous treatment, she developed prominent dystonia of the left upper limb. Cranial nuclear magnetic resonance imaging showed an isolated lesion compatible with a tuberculoma in the left cerebellar hemisphere. Both the limb dystonia and the tuberculoma resolved with maintained antituberculous treatment. CONCLUSIONS: In the patient described, the presence of upper-limb dystonia ipsilateral to a focal cerebellar lesion and the resolution of the dystonia and the mass lesion following treatment suggest that the cerebellum or its connections to the thalamus and/or basal ganglia could be involved in the pathophysiology of the dystonia.
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2/28. Late clinical manifestation of cerebral tuberculomas in two children with tuberculous meningoencephalitis.

    We report on two children with cerebral tuberculomas leading to late dramatic clinical exacerbation after appropriate antituberculous chemotherapy and high-dose corticosteroids. A 6-year-old girl with tuberculous meningoencephalitis initially fully recovered. However, after 9 months of continuous therapy she presented with acute increased intracranial pressure caused by tuberculomas requiring rapid drainage of CSF. A 16-year-old boy with miliary pulmonary tuberculosis and severe meningoencephalitis had reached a stable condition for more than 10 months although still suffering from a left-dominant spasticity and motor dysphasia. Fifteen months after initiation of therapy he presented with an acute central paralysis of the left facial nerve, progressive hemiplegia, severe ataxia and increasing lethargy caused by a cerebral tuberculoma with a perifocal oedema. Prolonged treatment with antituberculous chemotherapy and high-dose corticosteroids led to complete recovery in the younger patient and marked improvement in the older patient who remains severely handicapped. CONCLUSION: patients with initially successful treatment of central nervous system tuberculosis should undergo an alert follow-up for the development of late cerebral tuberculomas. Treatment should consist of prolonged courses of antituberculous chemotherapy and high-dose corticosteroids.
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3/28. Peripartum tuberculosis as a form of immunorestitution disease.

    The aim of this study was to assess the clinical spectrum of peripartum tuberculosis from the perspective of immunorestitution disease. Of 29 patients with peripartum tuberculosis, 27 (93.1%) had extrapulmonary tuberculosis, 20 (69%) of whom were affected in the central nervous system. Twenty-two (75.9%) patients had no clinical features suggestive of tuberculosis during pregnancy. The median time from delivery to the onset of immunorestitution was 4 days, but treatment with anti-tuberculous therapy was delayed for a median time of 27 days after the onset of symptoms. Despite therapy, 11 (38%) patients died and 4 (13.8%) had residual functional deficits. Peripartum tuberculosis is an important differential diagnosis of postpartum fever (of unknown origin) without localized signs.
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4/28. The diagnostic difficulties of meningeal and intracerebral plasma cell granulomas--presentation of three cases.

    Meningeal and intracerebral plasma cell granulomas are uncommon inflammatory lesions of unknown etiology. In this paper the diagnostic difficulties in two patients with meningeal plasma cell granuloma and one patient with intracerebral plasma cell granuloma are described. The first patient had an intracranial extra-axial lesion, which was first diagnosed as a meningioma. One and a half years later she underwent a second resection for recurrent tumor growth and the diagnosis of a meningeal plasma cell granuloma was made. The second patient was treated for a central nervous system B-cell lymphoma but proved to have an intracerebral plasma cell granuloma in retrospect 11 years later. In the third patient tuberculous meningitis was considered to be the most likely diagnosis because infratentorial contrast-enhanced thickened meninges (pachymeningitis) were found together with a high protein level in the cerebrospinal fluid and a positive Mantoux test. However, pathological examination of an extra-axial, cervical lesion that was operated upon revealed a meningeal plasma cell granuloma. These cases show the importance of diagnosing a meningeal or intracerebral plasma cell granuloma correctly, since it has both therapeutical and prognostic implications.
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5/28. Intramedullary tuberculoma mimicking primary CNS lymphoma.

    The incidence of primary central nervous system lymphoma (PCNSL) has been on the rise in the setting of immunodeficiency syndromes such as acquired immune deficiency syndrome (AIDS). Its diagnosis has been facilitated by the advent of a cerebrospinal fluid (CSF) Epstein-Barr virus (EBV) PCR assay. The reported high sensitivity and specificity of this assay has made it the cornerstone of diagnosis of PCNSL, replacing more traditional methods such as an open CNS biopsy. Here, we have described a patient with a known history of C3 AIDS presenting with lower extremity weakness and eventual myelopathy who was later diagnosed as having intramedullary PCNSL after detection of EBV dna in his CSF. After failing to respond to radiotherapy, he underwent a spinal cord biopsy revealing intramedullary tuberculoma. This case illustrates the risk of misdiagnosis with this assay and the importance of histological confirmation of a pathological lesion prior to implementation of therapy.
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6/28. Tuberculous meningitis with multiple intracranial tuberculomas mimicking neurocysticercosis clinical and radiological findings.

    central nervous system (CNS) tuberculosis (TB), the most dangerous form of TB, remains a public health problem, particularly in developing countries. In the differential diagnosis of intracranial tuberculomas (ICTs), images on radiological findings should be differentiated from other causes of space-occupying lesions. These lesions include malignant diseases such as glioma or lymphoma, pyogenic abscess, toxoplasmosis, neurocysticercosis (NC), sarcoidosis, hydatidosis and late syphilitic involvement of CNS. We present a case with multiple ICTs mimicking NC with similar clinical and imaging manifestations in a young immunocompetent patient. The diagnosis was based on brain magnetic resonance imaging findings. The definitive diagnosis was confirmed mycobacteriologically in cerebrospinal fluid and sputum specimens. Adequate response to anti-TB chemotherapy was achieved while multiple ICTs in the brain disappeared slowly. In the absence of appropriate therapy, these pathologies might be fatal; the possibilities of differential diagnosis would be of great clinical importance, particularly because of the different treatment protocols required for the NC and ICTs.
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7/28. Complex clonal features in an mycobacterium tuberculosis infection in a two-year-old child.

    The focus of this report is to describe the highly complex clonal features of the mycobacterium tuberculosis (MTB) isolates cultured from a 2-year-old child with no risk factors for tuberculosis. Molecular analysis showed that she was coinfected by 2 MTB isolates. The coinfecting isolates showed only subtle genetic differences and shared equivalent infectivity in vitro; however, they were infecting independent anatomic sites (compartmentalized infection). One of the MTB isolates was cultured only from respiratory specimens, whereas the other was isolated from extrarespiratory site (central nervous system).
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8/28. Neurosarcoidosis--demonstration of meningeal disease by gadolinium enhanced magnetic resonance imaging.

    Arriving at a firm diagnosis of neurosarcoidosis continues to pose serious problems, particularly when evidence of granulomatous disease outside the nervous system is lacking. The commonest mode of presentation of neurosarcoidosis is with cranial nerve palsies. Two cases of presumed neurosarcoidosis with cranial nerve palsies showed clear evidence of focal meningeal disease on gadolinium-DTPA enhanced MRI brain scans. Although not specific for sarcoidosis, this technique may be very useful in aiding the diagnosis in suspected cases.
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9/28. central nervous system tuberculosis in children.

    The incidence of tuberculosis in the united states is increasing in all age groups; 5% of all of these patients have central nervous system involvement. We studied childhood central nervous system tuberculosis between 1979 and 1989 and reviewed the literature for patients up to 14 years of age. The small number of patients reported in this country results in delayed diagnoses because of reduced awareness. Cranial computed tomography within 1 week of initial symptoms may reveal basilar enhancement, hydrocephalus, or infarction. When combined with cerebrospinal fluid findings atypical for common bacterial infection, these radiographic findings support the prompt initiation of antituberculous therapy. Prophylactic considerations are also discussed.
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10/28. Whither short-course chemotherapy for tuberculous meningitis?

    Short-course chemotherapy is well established for the treatment of pulmonary tuberculosis but not for extrapulmonary disease. We present a series of 35 cases in which chemotherapy for tuberculous meningitis was given for a period of less than 2 years. Short-term therapy was associated with recrudescence of tuberculous meningitis and, in some cases, with the development of deep cerebral infarcts and permanent neurological deficits. We think short-term chemotherapy for tuberculosis of the central nervous system is inadequate.
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